Neurology Notes for Boards Dyanne P. Westerberg, DO

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Neurology Review

Dyanne P. Westerberg, DO FAAFP

Associate Professor and Chair, Department of Family and Community Medicine

Cooper Medical School of Rowan University

Cranial Nerve Type Function

Olfactory 1 S Smell

Optic 2 S Sight

Oculomotor 3 M Medial, superior and inferior rectus , inferior oblique, ciliary muscle, sphincter muscle of the eye

Trochlear 4 M Superior Oblique

Trigeminal 5 B Sensation of face, muscles of mastication

Abducens 6 B Lateral Rectus

Facial 7 B Taste ( anterior 2/3 tongue) muscle of facial expression, stapedius muscle, stylohyoid muscle, digastric muscle, lacrimal, submandibular and sublingual glands

Vestibulococular (Auditory)

8 S Hearing and balance

Glossopharyngeal 9 B Taste( posterior 2/3 tongue) Pharyngeal sensation, parotid gland, styrlopharyngeus muscle

Vagus 10 B Sensation of trachea, esophagus,viscera,laryngeal,pharyngeal muscles, visceral autonomics

Accessory 11 M Sternocleidomastoid and trapezius muscle

Hypoglossal 12 M Tongue

Overview of the CNS arterial supply. Nolte, John, PhD - Essentials of The Human Brain, 37-42 © 2009 Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

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Lateral ( A ), medial ( B ), and cross-sectional ( C ) views of the hemisphere showing the regions served by the anterior cerebral ( green ), middle cerebral ( blue ), and posterior cerebral ( pink ) arteries. The distal territories of these vessels overlap at their peripheries and create border zones. These zones are susceptible to infarcts ( C ) in cases of hypoperfusion of the vascular bed. Small border zones also exist ( A ) between superior ( green ) and inferior ( blue ) cerebellar arteries. Haines, D.E.,Lancon, J.A. - Fundamental Neuroscience for Basic and Clinical Applications, 109-123.e1 © 2013 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.

Headache • Primary

– Migraine – Cluster – Tension

• Secondary – Hemorrhage – Encephalopathy – Meningitis – Temporal arteritis – Neoplasm – Sinus – Exertional – Trauma

Which headache is the most common?

Tension accounting for 40%

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Migraine Cluster Tension

Patient 10 to 30 years F>M

Young Men F>M

Types Without aura With aura

Precipitating factors Stress, BCP, menstruation, exertion, food containing tyramine or nitrates, chocolate, cheese, processed meats

ETOH, vasodilators Stress, fatigue

Associated symptoms photophobia, visual abnormalities, aura

Horner’s syndrome, lacrimation nasal congestions Pain radiates to the jaw and teeth

Anxiety

Duration 4 to 72 hours 30 Min to 3 hours

Variable

Treatment NSAID, ergots,triptans, Antiemetics, prophylaxis: tricyclics, Bblockers Calcium channel blockers Ergots, OMT

Also, 100% oxygen 7 L/minute for 15 minutes, OMT

Also relaxation exercises. OMT

Characteristics of the headaches

Migraines Cluster Tension

Nausea Photophobia/phonophobia Increase with activity P-pulsatile quality O- onset 4 to 72 hours U-Unilateral N- N/V D- Disabling Aura- flickering lights, spots Fully reversible neurological symptoms

Can be bilateral Several per day ( 1 to 8) Between 15 and 180 minutes Episodes 6 to 12 weeks Remission for 12 months

Bilateral Like a tightening band around the head Non pulsating No increase with physical activity No N/V No Photophobia/Phonophobia

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Characteristics of the headaches

Migraines Cluster Tension

Nausea Photophobia/phonophobia Increase with activity P-pulsatile quality O- onset 4 to 72 hours U-Unilateral N- N/V D- Disabling Aura- flickering lights, spots Fully reversible neurological symptoms

Can be bilateral Several per day ( 1 to 8) Between 15 and 180 minutes Episodes 6 to 12 weeks Remission for 12 months

Bilateral Like a tightening band around the head Non pulsating No increase with physical activity No N/V No Photophobia/Phonophobia

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Medical Treatments

Acute

• Acetaminophen/Aspirin/Caffeine

• NSAID

• Triptans

• Antiemetics

• Dexamethasone

• Ergotamine

• Intranasal Lidocaine

• Isometheptene

Chronic – First Line

• Propanolol

• Amitriptyline

• Sodium Valproate

• Topiramate

• Divalproex

Exertional Headache

• Headache after physical activity • Running

• Coughing

• Sexual Intercourse

• Bowel Movement

• Evaluation i.e. MRI if • >40

• Vomiting

• Prolonged duration

• Cardiac evaluation if risk factors

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Meningitis

• Infection of the covering of brain and spinal cord- meninges

• Risk Factors: ear infections, sinusitis, immunocompromise, neurosurgery, maternal group B infection during childbirth

• H and P: headache, neck pain, photophobia, nausea, vomiting, confusion, fever, seizure, Kernig, Brudzinski, rash

Meningitis by Age Age Most common

organism Other organism Emperic Treatment

Newborn Group B strep E.Coli, Listeria H.influenza

Ampicillin Cefotaximine

1 m to 2 y S.pneumonia N.meningitis

Group B Strep Listeria, H.influenza

Vancomycin Ceftriaxone

2-18 y N.meningitis S.pneumonia Listeria

Vancomycin Ceftriaxone

18 to 50 y S.pneumonia N.meningitis Listeria

Vancomycin Ceftriaxone

50+y Altered cellular immunity Alcoholic

S. pneumonia N. Meningitis, Listeria , gram-negative rods

Vancomycin Ceftriaxone Ampicillin

Viruses

• Viral Meningitis:

– Numerous viruses -Enteroviruses most common

– Nausea, vomiting, headache stiffness

– LP helps in diagnosis, more specific- PCR testing

• Encephalitis:

– Numerous viruses i.e flavivirus- West Nile*

– Headache, vomiting, change in mental status

* Increased incidence since 1999

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LP findings

Patient WBC Pressure Glucose Protein

Healthy <5 50-180mm H20

40-70 mg/dl 20-45mg/dl

Bacterial Increased Esp. PMN

increased decreased increased

viral Increased Esp. Lymphocytes

increased normal normal

Fungal or TB Increased Esp. Lymphocytes

Increased decreased increased

Prevention

• Vaccines for general population and aspleenic patients

– Hib Vaccine

– Pneumococcal Vaccine

– Meningococcal Vaccine

Trigeminal Neuralgia

• Recurrent- Head and Facial Pain in the trigeminal area- made worse by palpation with radiation to the maxillary and mandibular areas.

• F> M

• age >50

• MRI to r/o lesions such as tumor or MS

• Treatment: carbamazepine 200 to 1,200 mg/day recommended

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Temporal( giant cell) Arteritis

• Caused by subacute granulomatous inflammation of the external carotid and vertebral arteries

• Pain in the temporal region and radiating to the scalp and jaw. Transient or permanent blindness

• May be associated with polymialgia rheumatica

• Increased sed rate

• Biopsy for diagnosis

• Prednisone, ASA to reduce risk of stroke

Trigeminal Neuralgia Temporal Arteritis

TIA • American Heart Association/American Stroke

Association 2009 definition of TIA – Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction

• Underreported

• Sudden onset of unilateral paresis, speech disturbance, transient monocular vision loss

• NOT tinnitus, dizziness, vertigo, memory loss

( mimics)

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Evaluation

• Thorough History – Is it recurrent?

• Physical exam esp. neuro

• Imaging- within 24 hour – Diffusion weighted MRI

– CT scan often completed in the ER

• Cardiac Assessment: – EKG

– Transthorasic echo/TEE • Patent foramen ovale, thrombus, valvular disease

– Telemetry

– Labs

Treatment- prevent future strokes 10 to 20 % risk at 90 days often within 48 hours

• Modify risks: – hypertension, smoking, obesity, inactivity etc.

• Statins regardless of LDL: – Reduce by 50 % or less than 70

• Antiplatelets if non cardiac – 81 mg aspirin

– Dipyridamole/aspirin

– Clopidogrel

• Carotid endarterectomy or angioplasty – If 70 to 99% blocked and risk <6%

Treatment- prevent future strokes 10 to 20 % risk at 90 days often within 48 hours

• Modify risks: – hypertension, smoking, obesity, inactivity etc.

• Statins regardless of LDL: – Reduce by 50 % or less than 70

• Antiplatelets if non cardiac – 81 mg aspirin

– Dipyridamole/aspirin

– Clopidogrel

• Carotid endarterectomy or angioplasty – If 70 to 99% blocked and risk <6%

Not ASA and Plavix

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Atrial Fibrillation ( AHA)

• Warfarin with INR between 2 and 3 • Control group 4.5 % stroke

• Warfarin group 1.4% stroke

• Other agents: ( Do NOT have AHA approval)

– Dabigatron- (Pradaxa)

– Rivaroxaban (Xarelto)

– Apixaban (Eiquis)

Who needs anticogulation?

Stroke

• symptomatic cerebral ischemic events of > 24 hour duration

– 80%-87% ischemic ( thrombus or emboli)

– 13%-20% hemorrhagic

• Intracerebral

• subarachnoid

• Risk Factors: Age, FMH, obesity, DM, HTN, tobacco, AFIB, Stress, High Alcohol

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Acute Treatment • EKG • Labs • Imaging to r/o Bleed • Thrombolytic Therapy if within 3 hours if acute and

clinically meaningful defecit • No bleed or AV malformation • Normal platelets • No anticoagulants • No trauma • BP < 185/110

• oxygen if hypoxic • Aspirin within 48 hours ( if no thrombolytics) • Do not lower BP unless extreme i.e. 220/120 or patient

has CAD to maintain cerebral perfusion • Monitor for complications i.e seizures, edema, bleed

Imaging

• For diagnosing ischemic stroke in the emergency setting: – CT scans (without contrast enhancements)

• sensitivity= 16% specificity= 96%

– MRI scan • sensitivity= 83%specificity= 98%

• For diagnosing hemorrhagic stroke in the emergency setting: – CT scans (without contrast enhancements)

• sensitivity= 89%specificity= 100%

– MRI scan • sensitivity= 81%specificity= 100%

Seizure

• Sudden change in neurological activity (e.g. behavior, movement, sensation) causes by excessive synchronized discharge of cortical neurons in a limited (focal) or generalized distribution of the brain.

• Epilepsy: 2or more seizures that are not precipitated by illnesses or other inciting events i.e. alcohol withdrawal

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Common Causes of Seizure by Age Group

• Infant – Hypoxic injury

– Metabolic defect

– Genetic or congenital abnormality

– infection

• Children – Idiopathic

– Infection

– Fever

– trauma

• Adult – Idiopathic

– Metabolic defect

– Drug or drug withdrawal

– Trauma

– Neoplasm

– Infection

– CVA or stroke

Types of Seizures Type Involvement Comments

Simple Partial Focal, cortical region of the brain

Focal sensory of motor deficit with no LOC

Complex Partial Focal Region of the temporal lobe

Hallucinations and repeated coordinated movements

Generalized Bilateral cerebral cortex Tonic- clonic repetitive contraction and relaxation

Absence Bilateral Cerebral cortex Mostly in children

Status Epilepticus

• Either > 30 minutes of continuous seizure activity or ≥ 2 sequential seizures without recovery of full consciousness between seizures

• Due to : numerous- infections , brain tumor

• Treat with IV benzodiazepines, then start phenytoin or phenobarbitol if refractory

• Mortality > 20 % if untreated.

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Febrile Seizures

• Between age of 6 months and 5 years • Prevalence 2 to 5% • Males > female • No evidence of intracranial infection • Simple < 15 minutes, complex > 15 minutes. • Greater risk of developing epilepsy • LP should be performed in patients

• < 12 months • Complex seizure • Symptoms of meningitis

Parkinson Disease • Idiopathic dopamine depletion:

– loss of dopaminergic striated neurons in the substantia nigra and Lewy formation leading to abnormal cholinergic input to the cortex.

• Symptoms: – Resting tremor: pill rolling – Cogwheel rigidity – Bradykinesia/ akinesia- shuffling gait – Mask-like faces – Memory loss – Difficulty initiating movement – Postural instability – Stooped posture, decreased arm swing

Parkinson Disease • Idiopathic dopamine depletion:

– loss of dopaminergic striated neurons in the substantia nigra and Lewy formation leading to abnormal cholinergic input to the cortex.

• Symptoms: – Resting tremor: pill rolling – Cogwheel rigidity – Bradykinesia/ akinesia- shuffling gait – Mask-like faces – Memory loss – Difficulty initiating movement – Postural instability – Stooped posture, decreased arm swing

TRAP

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Treatment of Parkinson Disease Drug Mechanism indication

Levodopa Dopamine precursor Initial therapy

Carbidopa Dopamine decarboxylase inhibitor that reduces levodopa metabolism

Combined with levodopa to augment effects

Bromocriptine Dopamine receptor agonist Increases response to levodopa in patients with declining response

Selegiline Monamine oxidase type B inhibitor

Early disease – may help delay need to start levodopa

Amantadine Increases synthesis, release or reuptake of dopamine

More effective against rigidity and bradykinesia

Antimuscarinic agents

Block cholinergic transmission

Adjuvant therapy

Drug induced Parkinson Disease

• the older major tranquilizers such as Haloperisol ( Haldol), Trifluoperazine (Stelazine)

• the newer major antipsychotic drugs such as Risperidone (Risperdal), Olanzapine (Zyprexa),

• drugs used for nausea, vomiting, and acid reflux such as Metoclopramide (Reglan)

Myasthenia Gravis

• Autoimmune disorder • Antibodies bind to acetylcholine receptors at

neuromuscular junctions and block normal neuromuscular transmission

• Bimodal distribution younger women, older men • H and P

• Fatigue • Ptosis • Diplopia • Dysphagia • Dyspnea

• Lab: + positive Ach receptor antibodies • Tensilon Test: symptoms improve with edrophonium

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Guillain Barre Syndrome

• Inflammatory neuropathy associated with progressive weakness usually symetrical and ascending

• Autoimmune • Can be associated with recent viral infection, surgery ot

immunization • Peak 20’s and 70’s • Self resolving in 1 month- sooner with plasmapheresis or

immunoglobulin • H and P:

• Rapid bilateral weakness in distal extremities in stocking/glove distribution and going proximal

• Decreased sensation • Absent DTR’s • Respiratory Failure

Amyotrophic Lateral Sclerosis

• Progressive neuro degenerative disease of the motor neurons

• Loss of central nervous system – lower motor neurons

» anterior horn cells in spinal cord

» cranial nerve nuclei (most often X, XI, XII)

– upper motor neurons

» corticospinal tract

• Ages 20 to 80

Amyotrophic Lateral Sclerosis

• H and P – Asymmetrical progressive weakness in the limbs and

face – Possible change in personality and impaired judgment – Increase or decrease in DTR – Flaccid paralysis – Babinski – Fasciculations of the muscles

• EMG: Widespread muscular denervation and motor block

• Treatment: riluzole- supportive therapy

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Alzheimer’s Disease

• Most common cause of Dementia • Due to neurofibrillary tangles, neuritic plaques, amyloid

deposits,neuronal atrophy • Cortical atrophy on Imaging • H and P

• Progressive short term memory loss • Depression • Confusion • Inability to perform complex tasks or movements • Personality changes and delusions

• Treatment – Cholinesterase inhibitors – Memantine ( alone or in combination) – Herbals?????

Multiple Sclerosis

• Possible autoimmune

• Demyelinating disorder of brain and spinal cord

• Most patient women 20 to 40

• Mri with contrast shows white matter lesions

• H+ P: various symptoms, visual changes( Optic Neuritis- 10 year risk 38%), babinski, positional instabilities, spasticity, dysarrthria

• McDonald Criteria for diagnosis

• Treatment: steroids, methotrexate,interferon, glatirmer lacitate

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Radiculopathy Form of neuralgia due to irritation of the spinal nerve

Neuropathy Nerve Reflex Motor Deficit Sensory Deficit

C5 Biceps Deltoid, biceps Anterior Shoulder

C6 Brachioradialis Biceps, wrist extensor Lateral forearm

C7 Triceps Triceps, wrist flexors, finger extensors

Posterior forearm

C8 None Finger flexors Forth and fifth fingers, medial forearm

T1 None Finger interossei Axilla

L4 Patellar Tibialis anterior (foot dorsiflexiion)

Medial leg

L5 None Extensor hallucis longus (first toe dorsiflexion)

Lateral lower leg, first web space

S1 Achilles Peroneus longus and brevis( foot eversion) Gastrocnemius (foot plantarflexion)

Lateral foot

Osteopathic Manipulation

• Numerous studies support the use of OMT in the treatment of patients with musculoskeletal complaints.

• No studies on radiculopathy found.

• Many modalities- should not just think of high velocity techniques.

• High velocity should be used with caution in the cervical spine

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Carpal Tunnel

• Compression of the median nerve at wrist

• Ages 30 to 55

• F>M

• H and P

– Wrist pain radiates up the arm

– Decreased grasp

– Numbness in thumb middle and index finger

– Thenar atrophy in advanced cases

+ tinel + phalen

Treatment

• Most of questionable benefit

– Wrist splints

– Activity modification

– NSAID

– Steroid injections

– Surgical release of the transverse carpal tunnel ligament

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